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Flashcards in 7. ECG analysis Deck (54):
1

How is the heart rate shown on an ECG and how can you calculate this?

Heart rate is given by the RR intervals - the QRS complex is ventricular depolarisation

Count the number of R waves in 15 large squares and multiply by 20 (30 squares correlates to 6 seconds)

NB. the heart rate will usually be provided below on the rhythm strip

2

What is meant by the rhythm on an ECG?

The rhythm is essentially the regularity

Are the RR intervals the same throughout the whole strip? Or are they irregular?

3

What is indicated by the P wave and how long should this be?

P wave indicates atrial depolarisation

Should not be more than 2 squares long

4

What is indicated by the PR interval?

PR interval is the time taken for the electrical impulse to cross the AV node and propagate via bundle of His to the ventricles

i.e. from the atria to the ventricles

5

What is the normal range for the PR interval and what might an abnormal PR interval indicate?

PR interval should be 12-200ms i.e. 3 to 5 small squares

PR interval over 200ms usually indicates some form of heart block

Prolongation of the PR interval can also be associated with hypokalemia, acute rheumatic fever or carditis

6

Where is the QRS complex measured from?

From the start of the Q wave to the end of the S wave

7

What is indicated by the QRS complex?

Indicates the synchronisation of contraction of ventricular muscle

8

What is a long QRS complex indicative of?

Indicates that part of the ventricular muscle is not contracting normally

9

Give the normal values on an ECG for: rate, rhythm, P wave, PR interval, QRS duration

Rate: 60-100bpm
Rhythm: Regular
P wave: less than 80ms
PR interval: less than 200ms
QRS duration: less than 120ms

10

What is meant by sinus rhythm?

Sinus rhythm is a normal ECG with nothing abnormal
i.e. rate, rhythm, QRS duration, P wave, R wave and PR intervals are all normal

11

What is meant by sinus bradycardia?

This is where there is a low heart rate of less than 60 beats per minute

More spaced RR intervals but everything else is normal

12

Briefly describe sinus bradycardia

The rate is less than 60 beats per minute but everything else is normal i.e. normal rhythm, QRS duration, P waves and RR intervals

13

Why might sinus bradycardia occur?

May occur naturally in athletes where they have an enlarged heart
The increased size of the heart means that the diastolic filling time is longer - hence longer RR intervals

Can also be seen in patients on beta blockers

14

What is meant by sinus tachycardia?

Where there is a very high heart rate - greater than 100 beats per minute - originating at the SAN

The RR intervals are reduced

Everything else will be normal (including the PR intervals)

15

When might sinus tachycardia occur?

May be due to stress, fright, illness, exercise

Can be triggered by shock

NB. if no apparent trigger - medications may be required to suppress the rhythm

16

What is meant by ventricular tachycardia (pathophysiology)?

This is where improper electrical activity arises in the ventricles of the heart

The ventricles contract synchronously and produce a cardiac output but this is not controlled via the atrial contraction (SAN)

Can lead to rapid and irregular heart rhythm which can result in cardiac arrest

17

How is ventricular tachycardia shown on an ECG?

This ECG is very abnormal
No P wave is seen
QRS duration is prolonged
Very very high rate of around 180-190 beats per minute
The rhythm is generally regular

18

How does ventricular tachycardia differ to ventricular fibrillation?

VT is much more regular than VF
The rhythm and amplitude of the QRS complex is regular - it is just much faster than normal

19

What is meant by ventricular fibrillation?

Disorganised electrical signals - no sign of organisation or control of the electrical impulses

The ventricles quiver rather than contract in a rhythmic fashion

Blood is not pumped to the brain - the patient is generally unconscious

20

When might ventricular fibrillation occur and what how must the patient be treated?

May occur during or after a myocardial infarct

Patient should be immediately treated by a defibrillator (either internal or external)

21

How does ventricular fibrillation appear on an ECG?

Rhythm - irregular
Rate - very high, greater than 300
QRS duration - not recognisable
P wave - not seen

Very unfamiliar ECG pattern

22

What is meant by 'heart block' and where can it occur?

How can general heart block show on an ECG?

This is a disease/inherited condition
Causes a fault within the SAN due to an obstruction or block of the electrical conduction of the heart
A PR interval greater than 5 small squares indicates heart block

Can occur at the SAN, the AVN or just below the Bundle of His

23

What are the different types of heart block?

SAN blocks
AVN blocks - first second or third degree
Infra-Hisian blocks

24

Describe SAN blocks

This type of block will rarely give any severe symptoms because a total block at the SAN would simply result in the natural pacemaker of the heart being shifted to the AVN

25

Describe first degree AVN block and how it shows on an ECG

Regularly irregular PR intervals
PR interval lengthened beyond 0.20 at a regular rate - PR interval greater than 5 small squares
This condition rarely causes any problems by itself (minor)
Many athletes have this

26

Give the different names of second degree heart block?

Type 1 - Wenkenbach
Type 2

27

Describe the pathopysiology of type 1 (Wenkenbach) second degree heart block and how it appears on an ECG

Each successive impulse from the atria finds it more difficult to pass the AVN - problem with the electrical conduction from the atria to the ventricles

28

How does type 1 (Wenkenbach) second degree heart block appear on an ECG?

The PR intervals are lengthening throughout the ECG until the P wave is then not followed by a QRS complex - the system resets and repeats

29

Describe type 2 second degree heart block

The AVN randomly fails to respond to atrial impulses
The rate is irregularly irregular

30

Describe the pathophysiology of third degree heart block and what problems this can lead to

This is much more serious
Where conduction from the atria to the ventricles has failed completely
The ventricles are generating their own signal from a focus somewhere else in the ventricle
The ventricle often does not contract synchronously in this case and can lead to ventricular fibrillation
Bradycardia is often present as the abnormal ventricular contraction is usually slow
Patients with this will require a pacemaker

31

What is meant by atrial fibrillation?

Give the pathophysiology

Many separate sites in the atria are generating electrical impulses rather than just the SAN
Results in an irregular conduction of impulses to the ventricles
There is a general tachycardia
Can be felt when palpating a pulse
Very common in the eldery

32

How does atrial fibrillation appear on an ECG?

Cannot distinguish any P waves
Hence, cannot measure the PR intervals
Very high heart rate - of about 100-160 beats per minute (slower if on medication)
Normal QRS complex

33

What symptoms may be associated with atrial fibrillation?

Many cause no symptoms
Palpitations
Fainting
Chest pain
Congestive heart failure

34

What is meant by atrial flutter?

Give the pathophysiology

The SAN is firing too fast - rather than going into a proper refractory period, it fires immediately

SO there is synchronous contraction but more than one - the atria contract an extra time whilst the ventricles are still contracting (v similar to AF but only one abnormal excitatory focus)

Very high heart rate - around 110 beats per minute

35

How does atrial flutter appear on an ECG?

Very high heart rate so very frequent P waves - the P waves are replaced with multiple F (flutter) waves
Cannot tell the PR interval
Regular rhythm
Normal QRS complex

36

Compare the pathophysiology and the causes of atrial fibrillation to that of atrial flutter

Atrial fibrillation:
Multiple ectopic atrial pacemaker sites that compete with the SAN to stimulate atrial contraction
Can be caused by atrial dilation or enlargement associated with heart failure

Atrial flutter
There is only one atrial pacemaker re-activating itself and competing with the SAN
Can be due to an electrolyte disturbance or e.g. cardiomyopathy

37

What is meant by 'junctional rhythm'?

This is where there is damage to the SAN/conduction pathway in the atria
THE AVN TAKES OVER AS THE PACEMAKER
Bradycardia is present

38

How will junctional rhythm appear on an ECG?

Normal QRS complex
Absent P wave or if P wave is visible then it may be inverted in lead II
Hence, variable PR interval

39

What is meant by 'supraventricular tachycardia'?

General term for tachycardia in the atria
Can be due to atrial fib, atrial flutter or Wolff-Parkinson White syndrome
Can occur in all age groups

Very very high heart rate of around 140-220 bpm

40

How does supraventricular tachycardia appear on an ECG?

Regular rhythm
Normal QRS complex
P wave may be absent or there may be multiple

41

What is the patholphysiology of Wolff-Parkinson White syndrome?

Where there is an abnormal extra conduction pathway between the atria and the ventricles
This abnormal pathway is known as the bundle of Kent
Can stimulate the ventricles to contract prematurely

42

What is meant by AV nodal reentrant tachycardia (AVNRT)?

Give the pathophysiology

Most common type of sypraventricular tachycardia
Main symptom of palpitations

The AVN is reacitvated shortly after the first activation
Circuit usually involves two pathways in the right atrium - a fast one and a slow one

43

What are the different conditions that can cause variations in the P wave on an ECG?

Atrial fibrillation
Atrial flutter
Junctional rhythm
Supraventricular tachycardia
AVNRT

44

What condition can cause variations in the QRS complex on an ECG?

Bundle branch block

45

Give the pathophysiology of bundle branch block

Abnormal delay of the depolarisation of the ventricular muscle
Right bundle branch block - indicates a problem on the right hand side of the heart
Left bundle branch block - indication of heart disease

46

How does bundle branch block appear on an ECG?

There will be a prolonged QRS complex - delay in ventricular depolarisation
There may be a double R wave/a notch on the R wave - this is inducative of bundle branch block (good images in MIllar lecture)
Everything else will appear normal

47

What is represented by the ST segment?

The time when both ventricles are fully depolarised

48

How should the ST segment normally appear on an ECG and why?

The ST segment should be 'isoelectric' i.e. at the same voltage as the line immediately preceding the P wave

Hence should not be elevated or depressed

49

What is ST depression indicative of?

Can indicate coronary ischaemia or hypokalemia

ST depression can be present only on an exercise ECG and indicate angina or coronary heart disease

50

What is ST elevation indicative of?

ST elevation indicates STEMI - ST elevation Myocardial Infarct
For STEMI to be a diagnosis, the ST elevation must show in two or more adjacent ECG leads

51

How does STEMI appear on an ECG?

ST elevation
May be pathological Q waves (region of myocardium has undergone irreversible death)
R wave is prolonged and doesn't come all the way down to the isoelectric point

52

What is NSTEMI?

Myocardial infarction without ST elevation
Usually a less serious form - the cardiac ischaemia is present but not necessarily cardiac death

53

What is meant by the 'electrical axis' of the heart?

This is the mean direction of the action potentials travelling through the ventricles during depolarisation

54

How can you determine the electrical axis of the heart?

Use the QRS complex
Determine if the QRS complex is grossly positive or grossly negative in lead I and lead aVF
If overall positive, then the electrical axis is in the normal quadrant (between 0 and 90 degrees)
If it is positive in lead I but negative in aVF then the electrical axis for the heart is left axis deviated
If QRS complexes are both negative then the electrical axis is right axis deviated